Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Thursday, October 08, 2009

I'm writing about when things go wrong in psychiatric treatment. I have to say, we've gotten a lot of ideas for our book from our blog readers! We've heard a lot of stories about both loved and hated shrinks, and you've made us think about psychiatry in a new way.

I still think that lots of what we do is good. Over time, I've come to have a huge appreciation for the individual differences people have, and for how dismissive it may feel if those differences aren't appreciated. I've also come to appreciate that everyone is not helped by our worked, that sometimes the support and the relationship really help when the symptoms are unrelieved, and that when someone says "enough"...it's usually best to respect that.

I almost feel like I'm signing off here. But I'm not. Tell me your stories....

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comments:

Half the magic of healing is in the 'therapeutic' relationship itself, if you ask me. I kind of think it's funny that anyone has to learn a trade so people will see them so they can be helped, healed or cured.But then again, there is some element of magic in whatever art or healing craft one studies. I find that quite odd and am still trying to understand why that is the case.

(I'm very big on "healing occurs b/c of some dynamic of the patient/practitioner relationship." I just think people are magic). ;)

I had an unfortunate experience today with a new doctor who lectured my son and didn't listen to him (my son is a teen and I was part of the session.) The doctor threatened my son with all kinds of things if he did not comply with the doctor's recommendations. I thought he was way out of line.

My worst experience was with PHP (Partial Hospitalization) (Oct. 2005)) in which we attended in the daytime and went home at night. One guy was there because he was suicidal. He and two other guys in the group used to sit in the lounge during breaks discussing how they were planning to kill themselves. He had just lost his corporate job and he was having marital trouble. The psychologist ridiculed this guy one day when he jumped up and went to the blackboard and started drawing something on the board. The patient had just come from corporate America where such behavior was normal but the psychologist made fun of him in a cruel way. The psychologist was also a braggart. He told us that none of his patients had EVER committed suicide. He told us that once he asked for a commitment to not commit suicide (when they went home at night) nobody would suicide. The implication was that he (the psychologist) was such a hot shit therapist that he had magical powers. It struck me that the psychologist was daring the patients to commit suicide. Well, this really terrific patient (nice, sensitive, intelligent, good looking, accomplished, well-educated) left one day and killed himself. I wasn't suicidal and I wasn't in an ego struggle with the therapist so I watched this from the sidelines. However, he also put me down and discounted some things I said and did not believe other things I said that were just factual accounts of my life. He laughed and sneered for example when I said that I owned my own business and had been running it successfully up to and through the day of hospitalization. I then brought in a wedding album I had done just before I was hospitalized which I was very proud of (to try to prove that I really had been running a business) and he once again even in the face of proof of my livelihood discounted this as some sort of delusion of mine. I really have been a wedding photographer for 25 years. At the time I was in PHP, in the evenings I was working on wedding albums and calling clients. It is very disconcerting and maddening to be told black is white by a therapist. I did not believe his diagnoses of me either. Neither does the psychiatrist I have now been seeing for more than 2 years.I have names and dates of the above.I have lots of other bad experiences also. Very bad.

I decided to leave one particular psychiatrist for two reasons: First of all, the clinic he was working out of forced patients to get BOTH psychotherapy with a mental health counselor or LICSW or Ph.D. within their facility and then med checks & a certain number of psychiatric visits with their on-site M.D. Midway through treatment I had switched therapists, and since my therapy was now with someone outside of their clinic practice, I got kicked off the shrink's patient roster.

I couldn't have been more delighted, because just prior to that, I found out that the Geodon he had prescribed for me approx. 8 months earlier caused irregular and extremely late periods. He never explained this side effect to me (don't recall any side effects being explained), and being able to get pregnant was very important to me. Well, let me say, as a patient, I don't want sloppy psychiatry to interfere with my life as much as it did under that "healer's" watch. That's when I say, "I quit."

My biggest frustration arises when my psychiatrists and psychologists don't agree when it comes to what treatment I need or even what my problem is. One will initiate something and then the next will totally berate the idea to me.

Look, I just want to get better, but it's hard for me to have much faith when there is so much uncooperativeness and dissent among those who are supposed to be providing my care.

I have a significant track record of being difficult to help long-term, and the more psychiatrists and psychologist I see and the more treatments I try, the more discouraged I become that I will EVER find lasting relief.

I was just discharged after a 12-day hospitalization for suicidal ideations. The psychiatrist at the hospital discontinued my wellbutrin because he thought I should try an MAOI. I was actually hopeful or even optimistic because that's not something I had tried before, and maybe IT would help when most others had failed. I went back to my regular psychiatrist this morning, and he said the MAOI was a terrible idea and that I should resume the meds that I was taking prior to hospitalization two weeks ago... which were obviously working really well.

I'm not quite ready to give up on psychiatry and psychology entirely, but sometimes I really want to just throw up my hands, collapse into a defeated, sobbing heap, and call it quits for good.

I find treatment much more satisfying for all involved when the psychiatrist and the non physician therapist talk to one another regularly and them talk with the patient about those conversations. When the internist and any other providers also get to be part of the conversation.

They do not have to all agree, but sharing observations and perspectives enlightens everyone.

Tigermom, as an aside, lack of communication seems to be prevalent in many medical areas and not just psychiatry.

Anyway, Diana, thank you for giving us the opportunity to tell our stories even if they are negative which mine will be. You have been forewarned.

I decided to taper off my 4 psych med cocktail after suffering horrific side effects, including a hearing loss. Yes, I have definitely linked it to the med as when I screwed up my dose during tapering and took more, my hearing got worse.

Please understand that I realize that not all outcomes are going to be good and that side effects are to be expected. But what I do blame psychiatry for is that when you complain about side effects, your complaints are blown off due to your "illness" and it is assumed that you need more of the drug that is actually poisoning you.

Diana, it is interesting that you said that when someone says enough it is usually best to respect that. While my psychiatrist has many good points and I don't think he is a bad person, I don't feel that has generally occurred.

It is nothing he outrightly said but I can tell from his general line of questioning that he expects me to have a relapse any day. No comments that support what I want to do. As a result, I decided to see him as little as possible and to only go so I can get the prescription that I am tapering off of renewed. Why pay good money to someone who keeps expecting me to fail when I need all the support I can get for something that is one of the hardest things I will ever do in my life?

I also find that chilling in light of the fact he knows I am tapering off due to these side effects. Does he expect me to suffer those come heck or high water? I am sure that isn't his intention but that is the way it comes across.

Finally, psychiatry needs to stop misinterpreting withdrawals symptoms as the result of a too fast tapering schedule as a return of the illness. This is inexcusable and is a great disservice to the patient as it keeps them on drugs they don't need.

Many people like me have been able to taper meds at 10% of current dose every 3 to 6 weeks. Unfortunately, I am stuck on my final one due to rebound insomnia but if I hadn't gone slowly, I wouldn't have had the success I did.

But for some reason, psychiatry doesn't seem to accept a slow tapering schedule like mine. When I have suggested it, you would have thought I was suggesting a dangerous drug that would kill patients. It is like they don't want to deviate from something they have done a million years even though many people have suffered greatly due to too fast tapering schedules.

By the way, my tapering method could be used for patients who want to stay on meds but find the custom doses not appropriate. For example, if a patient found that 10 mg of Prozac was too much but 5mg was not enough, they could use a digital measuring scale (.001g) to perhaps measure out 7mg.

Instead, they are put through endless trial of meds that end being very hard on them physically and mentally.

I agree, in theory, that the "treatment team getting on the same page" is an excellent idea. However, recently I had an experience that has led me to question this... especially if this treatment team involves MDs who aren't exactly "psych minded."

While receiving treatment for MS, I was having additional problems with depression. At some point, my neuro felt it might be helpful to talk to my psychiatrist, whom I'd seen for yrs and who I had very good rapport with. It wasn't until I was having an increase in symptoms related to my MS, that I felt my neuro was "blowing me off" and eventually felt the need to switch neuros. While getting my records to take to the new MD, I began to understand what was going on. Turns out my neuro was pretty much convinced my increase in MS complaints were totally psyc in nature.. simply because of things my psych had told him. I was REALLY upset that I had been blown off for the past year, due to conversations between my MDs... when in fact my latest MRI (that new MD ordered)DID show an increase in disease progression. I felt very betrayed by my psych for apparently giving my neuro the impression I was a "head case" or something which led him to dismiss REAL symptoms I was having. I know I "shouldn't" be mad at my psych, but I am, and it's made me feel like I don't trust saying things to him now for fear that what I say may not be kept confidential.

Point is, for me, having my psych & neuro talk DID lead to delays in getting the medical treatment I needed. We as patients don't really know what all is being said..so if something is taken out of context, or there's some misunderstanding, we don't get the chance to explain or understand why one/both of the MDs make the treatment decisions they do.

I feel the PATIENT should be an equal participant in the treatment team! We certainly cannot be team players if everyone on the team has the playbook except us!! Just sayin...

Let's see...25 yrs of psych meds and therapy - therapy w/ LICSWs, meds initiated by psychiatrist, sometimes managed by PCP, sometimes by psych MD. Nortriptyline alone, then with lithium added, then SSRIsProzac, Paxil, Zoloft,Zoloft w/ Welbutrin,then SNRI Effexor XR - Paxil had no effect, Welbutrin had a full body rash. Others have worked well for significant periods of time. No real long time OFF meds in 25 yrs. First psych MD was OK, a bit paternalistic but what I needed at the start....second MD was a bad match from the start...her failure to make good eye contact or shake hands at our initial meeting turned out to be a predictor of this. (I was close to her in age and somehow I think I triggered stuff that made her feel she needed to put a distance btw. the 2 of us - she was recommended as a probable good fit by my long term therapist so I stuck with her longer than I should have, attributing the bad fit to my depression and not regaining faith in my own judgement for quite a while even after depression was easing)...eventually shifted to 3rd MD - she's young,good, attentive...but has gotten married and had a baby and cut down to very part time practice in the three years I've been seeing her...so I'm glad the current meds are working...and she "forgot" 2 appointments in that time frame which gave me LOTS of material to work on with my therapist..but I already knew I had abandonment issues and didn't really need her to bring them into the here and now so dramatically! Have also worked with psychiatrists collaboratively as a nurse, and can say there are good and bad like any other field, but they don't seem to know how much power they have in all of their actions and silences, for folks who are feeling fragile and desparate. And psych MDs don't like to admit how much their field is influenced by drug company marketing, and the reality that a lot of prescribing is art, not science. Many symptoms are chronic and can be ameliorated but not erased, and docs tend to minimize what this is like for clients....my second shrink at one point said to me 'well, you do have treatment resistant depression' in a tone that sounded like she did not expect me to ever feel WELL, and did not give me any HOPE! HOPE that things will get better is a key element of treatment, esp. in chronic illnesses of all sorts...HOPE and belief that the expert will not reject or abandon the client...

what doesn't work....when psychiatrists' arrogance doesn't allow them to recognize they are in over their head and need to refer onwards. I saw a board certified psychiatrist who came highly recommended by a friend for severe, treatment-resistant depression. The dr offered a good-sounding treatment plan...which he did not follow after step one. He did respond to my concerns. He did not return calls. He insisted on keeping me on a drug that I'd tried all the other drugs in it's class, and then on a different drug that led to cracked, scaly skin all over, dizziness, fainting, and cognitive impairment. I have a graduate degree in the hard sciences, and can read the studies; he would not respond to my concerns. His favorite response was "I've been doing this for 24 years and I know what I'm doing." Well, your majesty, I've been living in my body for 30 and I know what it's saying. In the end, I ended up hospitalized after about 6 months for a suicide attempt. My treatment team in the hospital couldn't understand why he had me on the meds I was on. (join the club....) I'm sure this guy is perfectly capable of treating mild to moderate mood disorders but.....severe depression? He should have known he was in over his head and referred me onwards. I've been in treatment with other therapists and psychiatrists that worked or didn't to different degrees, but those that didn't were ultimately based, i think, on personality differences. To me, my experience with the psychiatrist I discussed above is the epitome of failed treatment --- the arrogance (and yes, I agree it can sometimes be found in other medical specialties as well) that led to "I'm the doctor and I know best, and there's no way I could be wrong." Yeah, well, I was lucky I got out alive.

I was in a PHP program and I wasn't getting anywhere, but they wouldn't let me leave. And they kept trying to got me to confess my anger toward my dad. I was not angry at my dad. Eventually, I wrote a BS "angry" letter (not meant to be sent) to my dad and showed it to them. I was discharged the next day. They made their agenda quite clear.

I understand the tactic of "these are all the treatments we know of, so we are going to keep trying different ones until we find what works". That is fine. But there have been lots of times when they have not been willing to stop trying a treatment that wasn't working for me, or let me do something more that was working. I think that professionals tend to be better about this when it comes to medication than other treatments. If the medication isn't working and it's been given a fair trial, I haven't had much trouble in convincing them that it is time to try something new. But with things like CBT, yoga, affirmations, family therapy, I did have this problem. I would say, "yoga makes me hostile and anxious, I'm pretty sure that is counter-productive," but they would still send me to yoga and call me non-compliant for not participating.

With medication, it took very little to implement, but it was chosen much more thoughtfully. The other things took a lot more effort to implement, but there was hardly any thought given to it at all. That seems backward to me. Wouldn't you want to be more careful when more resources stand to be wasted?